Behavioral disturbance in dementia

Potentially dangerous behaviors for oneself and others are common in patients with dementia and are the primary reason for home nursing care in 50% of cases. The behaviors of such patients include wandering, restlessness, screaming, fighting, refusal of treatment, resistance to staff, insomnia, and tearfulness. Behavioral disorders accompanying dementia are not well understood.

Opinions about what patient actions can be classified as behavioral problems are largely subjective. Tolerance (what caregiver actions can be tolerated) depends to some extent on the patient's established routine, particularly safety. For example, wandering may be acceptable if the patient is in a secure environment (with locks and alarms on all doors and gates in the home), but wandering may not be acceptable if the patient leaves a nursing home or hospital because it may disturb other patients or interfere with the functioning of the facility. Many behavioral problems (including wandering, repetitive questioning, and contact problems) are less severe to others during the daytime. Whether sunset (exacerbation of behavioral problems at sunset and early evening) or true diurnal variation in behavior is significant is currently unknown. In nursing homes, 12-14% of patients with dementia have more behavioral problems in the evening than during the day.

Causes of Behavioral Disorders in Dementia

Behavioral disturbances may result from functional impairments associated with dementia: decreased ability to control behavior, misinterpretation of visual and auditory cues, decreased short-term memory (e.g., the patient repeatedly asks for something that he or she has already received), decreased or lost ability to express needs (e.g., patients wander because they are lonely, scared, or looking for someone or something).

Patients with dementia often adapt poorly to institutional settings. Many older patients with dementia develop or worsen behavioral problems when they are moved to more restrictive settings.

Somatic problems (e.g., pain, difficulty breathing, urinary retention, constipation, poor handling) may exacerbate behavioral problems, partly because patients cannot communicate adequately with others. Somatic problems may lead to the development of delirium, and delirium, superimposed on preexisting dementia, may worsen behavioral problems.

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Symptoms of behavioral disturbances in dementia

A better approach is to classify and specifically characterize behavior disturbances rather than label them as behavioral agitation, a term so general as to be of little use. Specific behavioral aspects, associated events (e.g., eating, toileting, medication administration, visits), and their onset and offset times should be recorded to help identify changes in the patient's overall behavior or assess their severity and to facilitate planning of treatment strategies. If behavior changes, a physical examination should be performed to rule out physical disorders and inappropriate handling, while environmental factors (including changes in caregivers) should be considered as they may be the underlying cause of changes in behavior rather than true changes in the patient's condition.

Psychotic behavior must be identified because its treatment differs. The presence of delusions and hallucinations indicates psychosis. Delusions and hallucinations must be distinguished from disorientation, anxiety, and confusion, which are common in patients with dementia. Delusions without paranoia may be confused with disorientation, whereas delusions are usually fixed (e.g., the patient repeatedly calls an asylum a prison), and disorientation is variable (e.g., the patient calls an asylum a prison, a restaurant, and a house).

Treatment of behavioral disorders in dementia

Approaches to the treatment of behavioral disorders in dementia are controversial and have not yet been fully studied. Supportive measures are preferred, but drug therapy is also used.

Activities that impact the environment

The patient's environment should be safe and flexible enough to accommodate the patient's behavior without causing harm. Signs that the patient needs assistance should prompt the installation of door locks or an alarm system, which can help to insure a patient who is prone to wandering. Flexibility in sleep patterns and organization of the sleeping area can help patients with insomnia. Interventions used to treat dementia usually also help to minimize behavioral disturbances: providing orientation to time and place, explaining the need for care before it begins, encouraging physical activity. If the organization cannot provide an appropriate environment for an individual patient, transfer to a place where drug therapy is preferred is necessary.

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Support for caregivers

Learning how dementia causes behavioral problems and how to respond to behavioral problems can help family members and other caregivers provide care and cope better with patients. Learning how to manage stressful situations, which can be significant, is essential.

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Medicines

Drug therapy is used when other approaches are ineffective and medication is necessary for patient safety. The need for continued drug therapy should be assessed monthly. Drugs should be selected to correct the most persistent behavioral disturbances. Antidepressants are preferably from the group of selective serotonin reuptake inhibitors and should be prescribed only to patients with symptoms of depression.

Antipsychotics are often used despite the fact that their effectiveness has been shown only in patients with psychotic disorders. In other patients (without psychotic disorders), success is unlikely, and there is a risk of side effects, especially extrapyramidal disorders. Tardive (delayed) dyskinesia or tardive dystonia may develop; these disorders often do not improve even when the dose is reduced or the drug is completely discontinued.

The choice of antipsychotic depends on its relative toxicity. Conventional antipsychotics such as haloperidol have relatively low sedative effects and less anticholinergic effects but are more likely to cause extrapyramidal symptoms; thioridazine and thiothixene have less extrapyramidal symptoms but are more sedative and have greater anticholinergic effects than haloperidol. Second-generation (atypical) antipsychotics (eg, olanzapine, risperidone) have minimal anticholinergic effects and cause fewer extrapyramidal symptoms than conventional antipsychotics, but long-term use of these drugs may be associated with an increased risk of hyperglycemia and all-cause mortality. In elderly patients with dementia-related psychosis, these drugs also increase the risk of cerebrovascular accidents.

If antipsychotic drugs are used, they should be given in low doses (eg, olanzapine 2.5-15 mg orally once daily; risperidone 0.5-3 mg orally every 12 hours; haloperidol 0.5-1.0 mg orally, intravenously, or intramuscularly) and for short periods.

Anticonvulsants such as carbamazepine, valproate, gabapentin, and lamotrigine may be used to control episodes of uncontrollable agitation. There is evidence that beta-blockers (eg, propranolol, starting at 10 mg and titrating up to 40 mg twice daily) are useful in some patients with psychomotor agitation. In this case, patients should be monitored for hypotension, bradycardia, and depression.

Sedatives (including short-acting benzodiazepines) are sometimes used for short periods of time to relieve anxiety, but they cannot be recommended for long-term use.